It’s arguable most people’s dream to age at home, surrounded by friends and family with the occasional support from a neighbor or friend. But in reality, the future will be much less comfortable for most.
Lilia Jean Cardin has been a resident at Big Horn Senior Living for about seven years, but just two weeks ago leadership at the facility announced it would close its doors over the next two to three months. All the residents will have to find new living arrangements, whether that’s moving in with family, opting for expensive assisted living rates or moving hundreds of miles away to a skilled nursing facility that has so far survived the industry’s financial crisis.
Cardin could face an out-of-county move that would make it nearly impossible for her most trusted friend, Donna Wald, to visit.
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“When ever I come in I bring her her chocolates. She’s diabetic, but she eats them and she says ‘I don’t eat a whole lot.’ Yeah I know she does,” Wald said, laughing.
Cardin is 96 years old, wheelchair bound and has issues with short-term memory. She often doesn’t recognize Wald when she comes to visit.
Without close family, Cardin relies heavily on Wald who acts as her power of attorney and is her emergency contact at the nursing home.
When memory issues started to settle in, Cardin donated about $8,000 to a local church. When Wald realized that the organization was taking advantage of Cardin’s condition, she started managing Cardin’s finances for her.
Come December, Cardin will run out of money to pay the $7,000 monthly rate she’s been paying since residing in the nursing home. She is in need of care 24 hours a day from trained providers, and soon she will become completely reliant on Medicaid to cover the costs of living in a skilled nursing facility.
The Big Horn Senior Living complex is only one of the seven facilities that have closed in 2022, displacing dozens of elderly residents who need the most care and support.
As more facilities close, accessing a nursing home bed covered by Medicaid is becoming more and more difficult. While occupancy may be low at facilities throughout the state, the Medicaid beds in Montana are nearly full.
Most nursing homes limit the number of Medicaid patients they’re willing to take because of the deficit in Medicaid reimbursement. Taking in more Medicaid patients could spell disaster for surviving facilities as increases in residents leads to increased costs while Montana’s Medicaid reimbursement fails to cover those costs.
As a result, elderly residents are being shuffled around the state and region, ending up wherever there is a Medicaid bed available.
When Wald heard that Cardin may have to be moved as far away as Missoula, she knew visiting would be nearly impossible. Round trip, Wald would have to travel 848 miles to visit her elderly friend.
Isolation and depression among the elderly is a common issue, particularly when skilled nursing is needed. Poor mental health can have a devastating impact on overall health, and without the means for travel, it’s possible residents will die alone in an unfamiliar place. It’s a heart wrenching circumstance that administrators across rural Montana have witnessed more than once.
DPHHS Director Adam Meier told The Gazette in a July interview that some nursing home residents are fit to move into assisted living facilities, which are primarily private pay.
Federal Medicaid does not cover assisted living or home health services. Instead, these services fall under the Medicaid waiver program, which is made up of state funds that are carefully divided up.
There are a limited number of Medicaid waiver slots available, and while a Medicaid waiver can transfer to another facility with the resident, most assisted living facilities in Billings have met their self-determined Medicaid occupancy.
The Hi-Line Retirement Center in Malta narrowly avoided closure by transitioning from a nursing home to an assisted living facility.
The rules for assisted living are more relaxed and it’s less expensive to operate, said Duane Murray, administrator at the facility. Murray has had to limit his clientele to people with lower acuity needs and is only taking in locals.
While the transition should help him keep the doors open, the decision does come with some risks.
“Success depends on waiver money, and that’s not reliable,” Murray said. “You have to gamble on (waiver money) because the alternative is to close the doors.”
Meier suggests in-home care
While Wald would happily take Cardin in, Wald’s ranch home in Lodge Grass is multiple levels. It would be impossible for wheelchair-bound Cardin to live safely. Cardin’s fragility also makes her prone to falling.
Wald does have a long nursing career behind her and has the skills to care for Cardin, but Wald herself is 80 years old. In Cardin’s old age, stairs, stoves, cars, even household obstacles present new dangers.
Some displaced residents could move in with family and utilize in-home health services, Meier said. But in-home health also falls under the Medicaid waiver program and each patient must meet specific criteria for reimbursement.
In instances when Medicaid coverage would not apply, in-home health care is incredibly expensive.
Not to mention, there is a complete lack of infrastructure in rural Montana to support an increased demand for home health.
The state is short hundreds of caregivers while simultaneously leading the West in the silver wave. As baby boomers age, the demand for long-term, skilled nursing care will skyrocket.
COVID and greater occupancy
Ultimately, transferring patients to new facilities will increase occupancy at others hundreds of miles away.
Not only will moving residents away from their communities and families keep them confined and isolated, but lessons learned from the COVID-19 pandemic about infectious disease in congregate settings will be ignored.
Large facilities and facilities in urban locations are more likely to experience COVID-19 outbreaks, according to a study by David Grabowski, a health care policy professor at Harvard University.
The larger and more compact the facility, the more chances there are for deadly germs to be swapped among residents. Urban cities also tend to experience more intense COVID surges, leaving workers to bring in germs from their lives beyond the walls of the facility.
In general, nursing homes are set up with multiple residents in one room, separated only by a thin curtain, not ideal for infection control. There is an even more severe ratio of residents to bathrooms in nursing homes.
And Medicaid does not pay for private rooms. Yet modern, state of the art nursing home models that could draw more paying customers, quite fewer residents in a more intimate setting.
“The state wants us to change and keep up with the times, but (what they’re doing) isn’t what’s right for the future,” said Rose Hughes, executive director of Montana Health Care Association, which lobbies for nursing homes in the state. “There is no future where skilled nursing isn’t necessary. We are losing infrastructure just like we did a few years ago with mental health — and we all can see where that landed us.”
Hospital Swing Beds
As Bridger Rehab and Care Center is set to close in Bozeman and the Gallatin Rest Home has struggled to reopen its rehabilitation services due to staffing challenges, hospitals are bracing to have swing bed occupancy increase.
Swing beds in hospitals are utilized when a patient needs post-hospital care, but there are no beds available at a skilled nursing facility.
Between the dwindling beds in the community and the continued challenges with COVID outbreaks, Bozeman Hospital is seeing an uptick in their long-term care patients, said Michelle Kirsch, registered nurse and case manager at the hospital.
While hospitals are well equipped to care for patients in need of long term care, issues arise when high acuity patients are coming in.
“Challenges are alluded to making sure hospitals are able to take high-acuity patients. We want to make sure we can provide stabilizing care (for those coming in),” Kirsch said.
Family engagement also makes a huge difference in a patient’s recovery, but if going home isn’t an option, staying in the community is the next best choice.
“When a patient can go home it’s best for their mental health and best for recovery,” Kirsch said. “It’s hard if people can’t be placed in their community. People really need to respect patients and make sure we’re getting the best place for each person.”
Kirsch pointed to a devastatingly low Medicaid rate and its impacts on patients across the state. Montana hospitals serve a large number of Medicaid patients who don’t receive the same level of care as those with private insurance.
The nursing home crisis is a perfect example of Medicaid patients not being able to access quality care that is comparable to private pay facilities. When patients aren’t too sick, too old or too poor, life is golden.
“These residents don’t have a choice. It’s never anyone’s dream to be in this situation,” said Wendy Soulek, COO of Latis Enterprises that operates recently closed Bridger Rehab and Care Center. “There have been tears on every front.”